Promoting progress in child survival across four African countries: the role of strong health governance and leadership in maternal, neonatal and child health.

Despite numerous international and national efforts, only 12 countries in the World Health Organization's African Region met the Millennium Development Goal #4 (MDG#4) to reduce under-five mortality by two-thirds by 2015. Given the variability across sub-Saharan Africa, a four-country study was undertaken to examine barriers and facilitators of child survival prior to 2015. Liberia and Zambia were chosen to represent countries making substantial progress towards MDG#4, while Kenya and Zimbabwe represented countries making less progress. Our individual case studies suggested that strong health governance and leadership (HGL) was a significant driver of the greater success in Liberia and Zambia compared with Kenya and Zimbabwe. To elucidate specific components of national HGL that may have substantially influenced the pace of reductions in child mortality, we conducted a cross-country analysis of national policies and strategies pertaining to maternal, neonatal and child health (MNCH) and qualitative interviews with individuals working in MNCH in each of the four study countries. The three aspects of HGL identified in this study which most consistently contributed to the different progress towards MDG#4 among the four study countries were (1) establishing child survival as a top national priority backed by a comprehensive policy and strategy framework and sufficient human, financial and material resources; (2) bringing together donors, strategic partners, health and non-health stakeholders and beneficiaries to collaborate in strategic planning, decision-making, resource-allocation and coordination of services; and (3) maintaining accountability through a 'monitor-review-act' approach to improve MNCH. Although child mortality in sub-Saharan Africa remains high, this comparative study suggests key health leadership and governance factors that can facilitate reduction of child mortality and may prove useful in tackling current Sustainable Development Goals.

Global implementation survey of Integrated Management of Childhood Illness (IMCI): 20 years on.

OBJECTIVE: To assess the extent to which Integrated Management of Childhood Illness (IMCI) has been adopted and scaled up in countries. SETTING: The 95 countries that participated in the survey are home to 82% of the global under-five population and account for 95% of the 5.9 million deaths that occurred among children less than 5 years of age in 2015; 93 of them are low-income and middle-income countries (LMICs). METHODS: We conducted a cross-sectional self-administered survey. Questionnaires and data analysis focused on (1) giving a general overview of current organisation and financing of IMCI at country level, (2) describing implementation of IMCI's three original components and (3) reporting on innovations, barriers and opportunities for expanding access to care for children. A single data file was created using all information collected. Analysis was performed using STATA V.11. PARTICIPANTS: In-country teams consisting of representatives of the ministry of health and country offices of WHO and Unicef. RESULTS: Eighty-one per cent of countries reported that IMCI implementation encompassed all three components. Almost half (46%; 44 countries) reported implementation in 90% or more districts as well as all three components in place (full implementation). These full-implementer countries were 3.6 (95% CI 1.5 to 8.9) times more likely to achieve Millennium Development Goal 4 than other (not full implementer) countries. Despite these high reported implementation rates, the strategy is not reaching the children who need it most, as implementation is lowest in high mortality countries (39%; 7/18). CONCLUSION: This survey provides a unique opportunity to better understand how implementation of IMCI has evolved in the 20 years since its inception. Results can be used to assist in formulating strategies, policies and activities to support improvements in the health and survival of children and to help achieve the health-related, post-2015 Sustainable Development Goals.

The introduction of new policies and strategies to reduce inequities and improve child health in Kenya: A country case study on progress in child survival, 2000-2013.

As of 2015, only 12 countries in the World Health Organization's AFRO region had met Millennium Development Goal #4 (MDG#4) to reduce under-five mortality by two-thirds by 2015. Given the variability across the African region, a four-country study was undertaken to examine barriers and facilitators of child survival prior to 2015. Kenya was one of the countries selected for an in-depth case study due to its insufficient progress in reducing under-five mortality, with only a 28% reduction between 1990 and 2013. This paper presents indicators, national documents, and qualitative data describing the factors that have both facilitated and hindered Kenya's efforts in reducing child mortality. Key barriers identified in the data were widespread socioeconomic and geographic inequities in access and utilization of maternal, neonatal, and child health (MNCH) care. To reduce these inequities, Kenya implemented three major policies/strategies during the study period: removal of user fees, the Kenya Essential Package for Health, and the Community Health Strategy. This paper uses qualitative data and a policy review to explore the early impacts of these efforts. The removal of user fees has been unevenly implemented as patients still face hidden expenses. The Kenya Essential Package for Health has enabled construction and/or expansion of healthcare facilities in many areas, but facilities struggle to provide Emergency Obstetric and Neonatal Care (EmONC), neonatal care, and many essential medicines and commodities. The Community Health Strategy appears to have had the most impact, improving referrals from the community and provision of immunizations, malaria prevention, and Prevention of Mother-to-Child Transmission of HIV. However, the Community Health Strategy is limited by resources and thus also unevenly implemented in many areas. Although insufficient progress was made pre-2015, with additional resources and further scale-up of new policies and strategies Kenya can make further progress in child survival.

Impact of a critical health workforce shortage on child health in Zimbabwe: a country case study on progress in child survival, 2000-2013.

Despite notable progress reducing global under-five mortality rates, insufficient progress in most sub-Saharan African nations has prevented the achievement of Millennium Development Goal four (MDG#4) to reduce under-five mortality by two-thirds between 1990 and 2015. Country-level assessments of factors underlying why some African countries have not been able to achieve MDG#4 have not been published. Zimbabwe was included in a four-country study examining barriers and facilitators of under-five survival between 2000 and 2013 due to its comparatively slow progress towards MDG#4. A review of national health policy and strategy documents and analysis of qualitative data identified Zimbabwe's critical shortage of health workers and diminished opportunities for professional training and education as an overarching challenge. Moreover, this insufficient health workforce severely limited the availability, quality, and utilization of life-saving health services for pregnant women and children during the study period. The impact of these challenges was most evident in Zimbabwe's persistently high neonatal mortality rate, and was likely compounded by policy gaps failing to authorize midwives to deliver life-saving interventions and to ensure health staff make home post-natal care visits soon after birth. Similarly, the lack of a national policy authorizing lower-level cadres of health workers to provide community-based treatment of pneumonia contributed to low coverage of this effective intervention and high child mortality. Zimbabwe has recently begun to address these challenges through comprehensive policies and strategies targeting improved recruitment and retention of experienced senior providers and by shifting responsibility of basic maternal, neonatal and child health services to lower-level cadres and community health workers that require less training, are geographically broadly distributed, and are more cost-effective, however the impact of these interventions could not be assessed within the scope and timeframe of the current study.

Institution Based Prospective Cross-Sectional Study on Patterns of Neonatal Morbidity at Gondar University Hospital Neonatal Unit, North-West Ethiopia.

BACKGROUND: Every year, millions of babies are born and a large proportion of them are being admitted to hospital for various indications. This study was conducted to identify the general characteristics, disease spectrum and common causes of Neonatal morbidity and mortality at Gondar University Hospital, Neonatal Unit. METHODS: Institution based prospective cross-sectional study was conducted at Gondar University Hospital (GUH), Neonatal Unit, from January 1(st) to March 31(st), 2014. The study included 325 newborns who were admitted to the unit during the study period. The neonates were followed up using structured checklist and neonatal parameters like Neonatal sex, place of delivery, address, length of stay, gestational age, diagnosis and discharge conditions were transcribed into an electronic database for all observations. The primary outcome measures were death and cause of death. RESULTS: A total of 325 neonates were admitted during the study period. Of these, 75.1%, 23.1%, 1.2% and 0.6% were discharged improved, died, discharged with same condition and disappeared, respectively. Ten variables were found to have significant statistical associations with neonatal mortality after adjusting for demographic covariates: Prematurity (p < 0.001), Meningitis (p <0.001), Hemorrhagic Diseases (P <0.001), Hyaline Membrane Disease (P<0.001), Neonatal Sepsis (p <0.05), Meningitis (<0.05), Perinatal Asphyxia (p <0.05), Neonatal Seizure (p <0.05), Home delivery (p <0.05) and Meconium Aspiration (p <0.05). CONCLUSION: Our study showed that the common causes of neonatal mortality are almost similar with the previous evidences (problems of prematurity, Asphyxia and Sepsis).

Evaluation of pre-service training on integrated management of neonatal and childhood illness in ethiopia.

BACKGROUND: The Integrated Management of Newborn and Childhood Illness strategy equips health workers with essential knowledge and skills to effectively manage sick children with common neonatal and childhood diseases. Since in-service training is very demanding to achieve the desired coverage of training of health workers, pre-service training is taken as a solution. At the time of the survey, most public and some private health professionals' training institutions were conducting pre-service training. However, several concerns have been expressed on the training. Therefore, this survey was conducted to assess the status of pre-service Integrated Management of New-born and Childhood Illness training. METHODS: A cross sectional survey on health professional training institutes/schools to evaluate pre-service Integrated Management of Newborn and Childhood Illness training was conducted in November 2007. Data was collected using pre-tested questionnaires, focused group interviews with teachers and students, observation of students while managing sick children using Integrated Management of Newborn and Childhood Illness guidelines, and reviews of pediatric course outlines and other teaching/learning materials. Data was entered in computer and analyzed using SPSS for Windows version 12.0.1. RESULTS: Twenty nine health professionals' training institutions (34 academic programs) which have started pre-service training were included in the survey. Of the 34 programs 22 were diploma nursing, 6 Bachelor of Sciences nursing, 4 health officer and the remaining two medicine. Thirty (88.2%) programs have integrated it in their curriculum. All academic programs had at least one fulltime staff for Integrated Management of Newborn and Childhood Illness classroom instruction. Twenty nine (85.3%) programs had staff trained in case management skills. All the 34 academic programs taught health workers skills, 28(82.3%) used mixed approach. Integrated Management of Newborn and Childhood Illness was either incorporated for 21 (61.8%) or added to the previous teaching 11 (32.3%). The instructor to student ratio was low for most of the schools. Main challenges encountered in the pre-service teaching were constraints with trained staff and other resources each by 28 (82.3%) programs. Integrated Management of Newborn and Childhood Illness was included in student evaluation by all programs (100%). All students and instructors (100%) rated that Integrated Management of Newborn and Childhood Illness concept is very relevant or extremely relevant but majority said the time given was short. The over all mean score of students clinical practice was 63.5%. CONCLUSION: This study demonstrated that Integrated Management of Newborn and Childhood Illness was introduced into the teaching programs of most health professional training institutions. The most preferred teaching style was the mixed approach. Group discussion and demonstration were commonly used methods and Integrated Management of Newborn and Childhood Illness questions were included in students' evaluation in almost all programs. Shortage of IMNCI trained staff and teaching materials were major challenges. The use of teaching materials prepared for pre-service training like handbook and model chapter was limited. Instructors and students attitude towards IMNCI was very good. The students overall performance in managing sick child as per the IMNCI guidelines was above average. We recommend that the respective bodies at every level make every effort to strengthen IMNCI pre-service teaching through revisiting curricula, facilitating staff training, availing teaching materials and allocating adequate time. Exploring for an alternative/innovative and sustainable training approach is an assignment for all.

AMBAR as a public health index for assessment of malnutrition in children.

This is a prospective case control study conducted in Gondar College of Medical Sciences Hospital and Gondar Health Center from March 1998 to March 2000 to determine the value of different size "AMBAR" to assess malnutrition in children age 12 months - 59 months. A total of 191 cases and 191 controls were enrolled in this study. In the process, we have developed a modified form of measuring the arm circumference by using a locally made bracellet called "AMBAR" of three different sizes. Among the three different size "AMBARs", the one with an internal diameter of 4 cm was found to be the most appropriate size to diagnose Protein Energy Malnutrition (PEM) as compared to the Harvard standard with a positive predictive value of 87.6% and negative predictive value of 95%. However "AMBAR" with an internal diameter of 3.5 cm has shown a sensitivity of 29% and specificity of 100%. The positive predictive value was 100% and Negative predictive value was 58%. Since the sensitivity was very low for this size, we felt that, it would not be rational to continue computing for "AMBAR" with an internal diameter of 3.0 cm. Finally we have concluded that, assessment of malnutrition using "AMBAR" 4 cm is a fairly useful method which can be used by mothers/caretakers who do not know how to read and write. It is also technically simpler to apply and requires inexpensive and easily available apparatus.